Every finding on record at Fraser Health Center

Based on observation, document review, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served. This had the potential to affect all residents who consumed food from the kitchen. Findings include: Review of the facility ' s policy titled Food Preparation and Service dated 2001 revealed that Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after 4 hours. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. Observation on 04/09/25 at 5:00 PM of the tray line revealed there was no documentation that food temperatures had been taken at that time. Review of the food temperature logs provided by the Dietary Manager (DM) revealed for the time period from 01/01/25 until 04/10/25 revealed temperatures were not documented for all three meals or all the hot food items prepared for each meal. During an interview on 04/09/25 at 5:15 PM the DM said food temperatures were not being taken consistently. She said she had taken them prior to them serving but had not written them down yet. During an interview on 04/10/25 at 2:19 PM, the Director of Nursing (DON) said she expected that foods temperature was obtained and served at the appropriate temperature before it left the kitchen and was served to residents. She was not aware of any concerns. During an interview on 04/10/25 at 2:23 PM, the Administrator stated he expected that staff would take the temperature of foods to ensure that residents were served food at safe temperatures.

Based on record review, interview and policy review, the facility failed to ensure a residents' safety during a transfer after Resident (R)24 sustained a laceration to her leg during a transfer that resulted in a skin tear. This had the potential to affect residents who required staff assistance during transfers. Findings include: Review of the facility's policy titled Safe Lifting and Movement of Residents dated 2001 revealed that in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Review of R24's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderate cognitively impaired. Review of R24's Care Plan dated 08/19/24 and located in the residents' EMR under the Care Plan tab revealed no identified concerns with skin conditions related to fragile or edematous skin. Review of R24's Daily Charting revealed R24 assist/transfer was one person with no device. Review of R24's Nurse's Note dated 03/03/25 and located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN) 1 revealed, while writer and CNA [Certified Nurse Aide] were assisting resident with transferring from the bed to the weight chair, this write placed resident's right leg onto the foot pedal of the weight chair and a skin tear resulted to the right inner shin (ankle) area, 3cm [centimeter] by 3cm by 1cm skin tear was cleansed with wound cleanser. Review of R24's Skin assessment dated [DATE] revealed a skin tear to the right shin 3cm x 3cm x 0.1depth. Review of R24's Incident Report dated 03/03/25 written by LPN1 and signed closed by Assistant Director of Nursing (ADON) revealed while this writer and CNA were transferring resident into weight chair, this writer placed hand on resident's leg to assist her with putting her leg onto footrest and a skin tear occurred. During an interview on 04/09/25 at 7:19 PM, LPN1 stated she along with CNA3 were transferring R24 to the weight chair. She said that R24's leg was already edematous and when she picked up her leg, her hand just sunk into her leg. She said that when she touched her leg it just opened. She did not remember R24 leg hitting or touching anything during the transfer. She was unable to explain further how the injury occurred. During an interview on 04/10/25 at 8:55 AM, CNA3 said on 03/03/25 R24 was already on the edge of the bed with her legs hanging over bed and LPN1 was in the process of trying to transfer her. She said this was the first time she ever assisted with a transfer for R24. She said she used her gait belt and put it around R24's waist while LPN1 had her legs and feet. She was standing behind the weight chair, and once they had the resident onto the chair, LPN1 was moving her feet and CNA3 observed blood on the floor. She asked what happened, and LPN1 told her R24's leg went up and she got a skin tear. CNA3 said LPN1 did not explain what or how it happened exactly. CNA3 stated that during a transfer staff should not need to grab a resident's legs with their hand and would only need to place their hand gently on the back of the resident's legs and help guide their legs onto the bed or into a chair. During an interview on 04/10/25 at 9:42 AM, the ADON stated she did not know exactly how the injury occurred during the transfer but thinks it was just a result of thin skin. She said that R24 had skin that was fragile. She was unable to remember what the nurse stated happened during the transfer because she did not get a statement or ask the staff to write anything down. She said she was not sure if there was a technique error. The physician was made aware and had no concerns. She also said she did not inservice staff about transfers or handling residents with fragile skin after the incident. During an interview on 04/10/25 at 2:33 PM, the Director of Nursing (DON) stated that anytime an injury occurs when staff are providing care, staff should be talking with residents and staff to try to figure out what occurred. She was aware that R24 sustained an injury during a transfer, but she was unsure how exactly the injury occurred. But she expected staff to do an investigation to try and determine the cause.

Based on record review and interview, the facility failed to update a care plan for a resident who had a change in their skin condition for one of one resident (Resident (R) 24) reviewed for accident hazards. This deficient practice has the potential to affect residents who have a change in their plan of care. Findings include: Review of R24's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis of dementia. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderate cognitively impaired. Review of R24's Care Plan dated 08/19/24 and located in the EMR under the Care Plan tab revealed no skin conditions related to fragile or edematous skin. Review of R24's Nurse's Note dated 03/03/25 and located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN) 1 revealed, while writer and CNA [Certified Nurse Aide ] were assisting resident with transferring from the bed to the weight chair, this writer placed resident's right leg onto the foot pedal of the weight chair and a skin tear resulted to the right inner shin (ankle) area. 3cm [centimeter] by 3cm by 1cm skin Review of R24's skin assessment dated [DATE] revealed a skin tear to the right shin 3cm x 3cm x 0.1depth. During an interview on 04/09/25 at 7:19 PM, LPN1 stated she along with CNA3 were transferring R24 to the weight chair. She said that R24's leg was already edematous and when she picked up her leg, her hand just sunk into her leg. She said that when she touched her leg it just opened. She did not remember R24's leg hitting or touching anything during the transfer. During an interview on 04/10/25 at 9:42 AM, the Assistant Director of Nursing (ADON) stated she did not know exactly the injury occurred during the transfer but thinks it was just a result of thin skin. She said that R24's skin was fragile. The ADON confirmed R24's care plan had not been revised with some new interventions about handling residents with fragile skin while providing care. During an interview on 04/10/25 at 2:33 PM, the Director of Nursing (DON) said anytime an injury occurs when staff were proving care they should be looking at the care plan interventions and seeing what changes need to be made to the plan of care. The DON agreed there should be new interventions to R24's skin care plan.

Based on observation, record review and interview, the facility failed to ensure a dignified experience by ensuring a catheter bag that was in view of staff, visitors and residents was placed in a privacy bag for one of one resident (R25) reviewed for indwelling urinary catheter use. This had the potential to affect residents who require a catheter. Findings include: Review of R25's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE]. During an observation on 04/08/25 at 10:27 AM and on 04/09/25 at 1:05 PM, R25 was lying in bed with the indwelling urinary catheter bag hanging on the right side of the bed visible from the door. During an interview on 4/09/25 at 1:12 PM, Certified Nurse Aide (CNA)2 said it was the CNAs who placed the indwelling urinary catheter bag in a privacy bag when the resident left the room. But she stated it was a dignity issue when people can see it from the hallway and stated R25 was clearly seen from the hallway. During an interview on 04/10/25 at 9:59 AM, the Assistant Director of Nursing (ADON) said that typically during the day when the resident was in their room they did not put in a privacy bag on the catheter. But when they came out of their room they had a leg bag that was covered by clothing, During an interview on 04/10/25 at 2:46 PM, the Director of Nursing (DON) said that a indwelling urinary catheter bag should have been covered while they are in their room.

Based on observation, interview and record review, the facility failed to ensure accurate labeling and dating of foods and removal of expired foods from the Production Cooler. Findings include: Review of facility policy titled, Policy & Procedure Manual: Food Storage revealed Refrigerated food storage:. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed for their safe use by dates, or frozen (where applicable), or discarded. During observation on [DATE] at 11:19 AM, the Production Cooler contained opened, unlabeled cream cheese and two pieces of unlabeled cheese. There were 7 pieces of expired Boursin Garlic and Fine Gourney Cheese 5.2 pounds that had an expiration date of ,d+[DATE]. There was one expired 5-pound container of pimento spread with an expiration date of [DATE]. Interview on [DATE] at approximately 12:11 PM with the Certified Dietary Manager (CDM), revealed storage and labeling duties are completed by the receiver and all staff that utilize the storage areas. Interview on [DATE] at approximately 12:15 PM with the Executive Chef revealed, the receiver is responsible for receiving items, dating items, and rotating items. All staff that uses the storage area are responsible for rotating and discarding items. Interview on [DATE] at 11:21 AM with the Receiver revealed they are responsible for receiving incoming items, rotating items, updating items, and discarding expired and spoiled items. When items are in storage, and they are not dated, he puts the date that he sees the items. Staff from different areas utilize the storage area as well, and therefore some of those staff maybe not be labeling the items.

Based on observation, interview, record review, review of facility policy, the facility failed to prepare and administer medications according to the pharmacy label and as ordered by the physician for 1 of 27 observed opportunities during medication administration. Specifically, Registered Nurse (RN)1 crushed and administered an extended-release medication, a significant med error, which placed Resident (R)25 at risk for complications of a rapid release of potassium into the stomach and bloodstream. Findings include: Review of a Policy Statement, revised April 2018, documented, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders .1. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications. Review of R25's Detailed Summary documented R25 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; congestive heart failure and hypokalemia (low level of potassium in the blood). Review of R25's Physicians Orders documented an order dated 07/06/23 . May give meds crushed/whole in applesauce per pharmacy or physician order, except time released .Klor-Con M20 mEq tablet, extended release [Potassium chloride]- 1 TAB by mouth Once daily for abnormal finding of blood chemistry. Review of a red sticker on the pharmacy label for R25's Klor-Con medication, located in the medication cart, documented . Do not chew or crush before swallowing. Review of an undated document titled Medications Not To Be Crushed located in the narcotic notebook on the medication cart, documented potassium chloride .Klor-Con. During an observation on 07/26/23 at 8:30 AM, revealed RN1 poured R25's morning medications, including potassium Cl (chloride) ER (extended release) 20 MEQ (milliequivalents), into a medicine cup then proceeded to place it into a sleeve and crush. This Surveyor advised RN1 to double check to ensure all the medications could be crushed. RN1 said it was not necessary as the computer would alert her if the medication could not be crushed. RN1 put the crushed medications into yogurt and administered to R25. During an interview on 07/26/23 at 10:00 AM, RN1 confirmed the potassium extended-release medication should not have been crushed. During a phone interview on 07/26/23 at 11:22 AM, the Staff Pharmacist said the most immediate effect of the crushed extended-release potassium could be irritation to the throat or esophagus. The Staff Pharmacist said the resident could also experience a rapid heartbeat due to a quick release of potassium into the blood stream. The Staff Pharmacist said all medications that cannot be crushed have a red alert sticker on the pharmacy label and each of the medication carts had an extensive list of medications that should not be crushed. During an interview on 07/26/23 at 11:35 AM, R25 said she has never had throat irritation, upset stomach, or rapid heartbeat after taking morning medications.

Based on observation, interview, and review of facility policies titled Handwashing/Hand Hygiene and Departmental(Environmental Services)-Laundry and Linen, the facility failed to ensure infection control procedures were followed during the laundry process. Laundry staff was observed to enter multiple rooms without changing gloves, touching multiple items with soiled gloves, and enter into the nutritional room wearing the gown used during sorting for one of one laundry observation. The findings included: Observation of the laundry on 2/12/20 at 10:00 AM revealed Laundry Staff #1, after donning gown and gloves, entered into room [ROOM NUMBER] and placed loose clothing items into a bag. After exiting the room, s/he reached into his/her pocket, removed a pen, placed a piece of paper on the wall, wrote identifying information, and placed the paper with the bag of soiled items. Laundry Staff #1 entered into room [ROOM NUMBER] and repeated the process. In addition, prior to exiting the room, Laundry Staff #1 turned the lights off. Laundry Staff #1 opened the laundry door, loaded washer #1, sprayed Shout on the clothes, added detergent, closed the machine door, and started the washer. The same procedure was used for washer #2. After finishing the procedure for washer #2, Laundry Staff #1 removed the soiled gloves. Laundry Staff #1 exited the laundry room wearing the soiled gown, entered into the nutritional room on the unit and washed his/her hands. After washing his/her hands, Laundry Staff #1 re-entered the laundry room and did not remove the soiled gown until this surveyor questioned at what point would the gown be removed. After sharing the above concerns with Laundry Staff #1, s/he stated understanding of the concerns. Review of the facility policy titled Handwashing/Hand Hygiene revealed under the Policy Interpretation and Implementation the following: 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Review of the facility policy titled Departmental(Environmental Services)-Laundry and Linen revealed under the section of Washing Linen and other Soiled Items the following: 11. Remove barrier attire when leaving the soiled linen area.

Based on record review, observation, and interviews, the facility failed to ensure Resident #12 was as pain free as possible during pressure ulcer treatment for one of 2 pressure ulcer treatments observed. During pressure ulcer treatment, Resident #12 indicated the pressure ulcer treatment was painful. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. Record review on 2/11/20 at 3:57 PM revealed Resident #12 had an inherited, unstageable pressure ulcer to the left heel. Review of physician orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the physician's progress note dated 2/3/20 revealed Resident #12's left heel wound had eschar with drainage and debridement was recommended. Review of the Medication Administration Record(MAR) revealed Resident #12 received [MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg on [DATE] at 4:51 AM. Further review of the MAR indicated [REDACTED]. Observation of pressure sore treatment on [DATE] at 1:25 PM revealed during the removal of the dressing, cleaning of the wound, drying the wound, and placement of the new dressing, Resident #12 moaned or stated it hurt. During the care of the wound, using gentle technique, Registered Nurse(RN) #1 did not ask the resident if s/he would like the treatment stopped. During the treatment, RN #2 encouraged Resident #12. During an interview with RN #1 on [DATE] at 2:00 PM, s/he stated s/he knew the resident well and the behaviors exhibited were not new. RN #1 further stated during the visit to the wound clinic Resident #12 exhibited the behaviors even when the area was anesthetized. S/he continued when care was given, Resident #12 did not draw back his/her leg. RN#1 stated that s/he knew the surveyor wanted to see the wound care and s/he was focused on the wound care. On [DATE] at 2:13 PM, RN #1 added, the resident never asked me to stop the treatment. During an interview with the Director of Nursing on [DATE] at 2:05 PM, s/he stated during treatment if a resident moans or indicates the treatment is painful, the expectation of staff would be to ask the resident if the treatment needed to be discontinued and see if the resident could have pain medication. During an interview with Physician #1 on [DATE] at 2:25 PM, s/he stated Resident #12 moans or indicates it hurts during examinations on his/her visits. S/he continued by stating it was questionable if the resident was having pain or if it was just a behavior.

Based on observations, interviews and review of the facility policy titled, Food Storage, and Hand Washing and Personal Hygiene, the facility failed to follow procedures to ensure food was stored, prepared and distributed in accordance with professional standards for food service safety and has the potential to affect all residents eating meals prepared in the facility's kitchen. The findings included: An observation during initial tour of the kitchen on 10/29/2018 at approximately 11:15 AM revealed a container of Cool Whip that was opened and not dated, with the opened date, in the reach in cooler. Further observation on 10/29/2018 at approximately 11:15 AM, during initial tour of the kitchen revealed a box of sausage opened and not dated or sealed in the reach in freezer. An observation on 10/29/2018 at approximately 11:30 AM of the walk in freezer revealed boxes of frozen food stored on the floor and approximately 6 inches from the ceiling. An observation on 10/29/2018 at approximately 11:30 AM of the dry storage room revealed boxes of food stored on the floor. An interview on 10/29/2018 at approximately 11:30 AM with the Dietary Supervisor confirmed the above findings. An observation on 10/29/2018 at approximately 11:30 AM revealed the Dietary Supervisor with hair uncontained by a cap. The Dietary Supervisor was not wearing a hair net. An observation on 10/29/2018 at approximately 11:30 AM revealed a dietary worker with a cap and a long ponytail in the process of preparing chicken for the lunch meal. The dietary worker did not have his/hair contained. The Dietary Supervisor and dietary staff were observed again on 10/31/2018, during lunch prep, with their hair uncontained by a cap. An interview on 10/31/2018 at approximately 11:40 AM with the Dietary Supervisor confirmed the use of the cap and not a hair net. Review on 10/31/2018 at approximately 12: 28 PM of the facility policy titled, Food Storage, states, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored and prepared, and transported at appropriate temperatures and by methods to prevent contamination or cross contamination. Under Procedure, #11. states, Food is stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer waste disposal pipes, vents, etc.). Further review on 10/31/2018 at approximately 12:28 PM of the facility policy titled, Food Storage, states under umber 13, Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. Review on 10/31/2018 at approximately 12:30 PM of the facility policy titled, Hand Washing and Personal Hygiene, states under Policy: All employees will be instructed on good personal hygiene, and will be expected to maintain optimal hygiene. The Purpose, states, To maintain food safety and protect against foodborne illnesses. Under Procedure, 1. states. Hair restraints (hats and hairnets) are required to keep hair and its contaminants out of food.

Based on record review and interview the facility failed to ensure the medical records for Resident #6 contained complete and accurate information related to blood sugar monitoring for 1 of 5 residents reviewed for Unnecessary Medications. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review on 11/1/2018 at approximately 1:34 PM of the medical record for Resident #6 revealed nurses notes dated 7/22/2018 at 5:35 PM states, Resident BS (Blood Sugar) 517. Five units of Humalog given as per order. Physician aware, no new orders. Review on nurses notes dated 10/9/2018 at 12 PM states, Residents BS is 503. Five units of Humalog administered. Physician aware. Further review on 11/1/2018 at approximately 1:30 PM of the medical record for Resident #6 revealed the MAR (Medication Administration Record) dated 10/1/2018 through 10/31/2018. Review on 11/1/2018 at approximately 1:30 PM of the MAR indicated [REDACTED]. No documentation could be found in the nurses notes to ensure the monitoring of the elevated or low blood sugar. An interview on 11/1/2018 at approximately 1:52 PM with the DON (Director of Nursing) confirmed documentation was not found in the medical record for Resident #6 to ensure monitoring of elevated and low blood sugars.

Based on observation, record review, and interview, the facility failed to ensure residents were informed about the process of how to file a grievance. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if they knew how to file a grievance with the facility. The 4 active participants were unable to answer this question and indicated that they were unaware of this process. Observations during the survey indicated this information was located on a bulletin board in a hallway located down from the activity room. This hallway lead out of the unit into another section of the residential campus and was not frequented by all residents. Review of the Resident Council Meeting Minutes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed this information was not discussed during the Resident Council meetings. During an interview on 11/1/18, the Director of Nursing confirmed this finding.

Based on record review, interview and review of the facility policy titled, Residents Bill of Rights. the facility failed to ensure Resident #14 was afforded the right to make his/her own health care decision to receive or refuse the Influenza Vaccine for this current flu season. Resident #14 was not deemed unable to make own health care decisions for 1 of 6 residents reviewed for the Influenza Vaccine. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Resident #14 has a BIMS (Brief Interview for Mental Status) of 11 out of a possible 15 on 9/24/2018. Review on 11/1/2018 at approximately 10:45 AM of the medical record for Resident #14 revealed a form titled, Informed Consent for Influenza Vaccine, dated 9/20/2018 revealed a telephone consent provided by the Power of Attorney for Resident #14. Further review on 11/1/2018 at 10:45 AM of the medical record for Resident #14 revealed a form titled, Do Not Resuscitate, Consent Cognitive Resident, under Physician's Order states, Resident has the ability to understand and appreciate the nature and consequences of an order not to resuscitate, including the benefits and disadvantages of such an order, and to reach an informed decision regarding this order, The DNR was signed by the resident due to the fact that Resident #14 was not deemed unable to make his/her own health care decisions. An interview on 11/1/2018 at approximately 11:00 AM with the DON (Director of Nursing) confirmed that Resident #14 was not offered the right to make his/her own health care decision related to receiving or refusing the Influenza Vaccination for the current flu season. Review on 11/1/2018 at approximately 11:20 AM of the facility's Residents Bill of Rights, states, The resident has the right to a dignified existence, self-determination and communications with a access to persons in and outside the facility. The facility will protect the rights of each resident. Number 2 under, Resident has the right, To be fully informed, in language easily understood of his/her total health status and about care and treatment. Number 3 states, To refuse treatment, or participate in experimental research.

Based on interview and record review, the facility failed to provide information to residents related to residents rights. The facility failed to provide ongoing communication related to resident rights for 4 of 7 residents attending Group Interview. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if staff talks about and reviews the rights of residents in the facility during the Resident Council meetings. The 4 active participants were unable to answer this question and indicated that this was not done. Review of the Resident Council meeting minutes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed no documentation to indicate staff provided ongoing communication to residents about their rights. There was no documentation to indicate resident rights were discussed during any of the meetings. During an interview 11/1/18 at approximately 2:50 PM, the Activity Director confirmed that there was no documentation to indicate ongoing communication to residents about their rights and confirmed that he/she had not discussed resident rights during the Resident Council Meetings.

Based on record review, interview and review of the facility policy titled, Change in a Resident's Condition or Status, the facility failed to notify the Physician and the Personal Representative for Resident #6 of fingerstick blood sugars greater that 500 and less than 60 for 1 of 5 residents reviewed for Unnecessary Medications. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review on 11/1/2018 at approximately 1:34 PM of the medical record for Resident #6 revealed nurses notes dated 7/22/2018 at 5:35 PM states, Resident BS (Blood Sugar) 517. Five units of Humalog given as per order. Physician aware, no new orders. Review on nurses notes dated 10/9/2018 at 12 PM states, Residents BS is 503. Five units of Humalog administered. Physician aware. No documentation could be found to ensure the personal representative was notified of the elevated blood sugar. Further review on 11/1/2018 at approximately 1:30 PM of the medical record for Resident #6 revealed the MAR (Medication Administration Record) dated 10/1/2018 through 10/31/2018. Review on 11/1/2018 at approximately 1:30 PM of the MAR indicated [REDACTED]. No documentation could be found in the nurses notes to ensure the Physician and the personal representative were notified of the elevated blood sugar and the low blood sugar. Review on 11/1/2018 at approximately 1:30 PM of the physician's orders revealed an order dated 4/6/2017 which states notify the MD (medical doctor) for BS less than 70 and over 500. An interview on 11/1/2018 at approximately 1:52 PM with the DON (Director of Nursing) confirmed documentation was not found in the medical record for Resident #6 to ensure the physician and the personal representative were notified of elevated and low blood sugars. Review on 11/2/2018 at approximately 2:25 PM of the facility's policy titled, Change in a Resident's Condition or Status, states, Our facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical/mental and or status (e.g., changes in level of care, billing payments, resident rights, etc).

Based on record review and interview the facility failed to ensure a quarterly assessment for Resident #14 was coded accurately related to Hospice for 1 of 1 resident reviewed for Hospice Care and Services. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review on 11/1/2018 at approximately 11:33 AM of the MDS (Minimum Data Set) quarterly assessment dated [DATE] indicated this MDS was not coded for Hospice. Resident #14 was admitted to Hospice on 7/6/2017. An interview on 11/2/2018 at approximately 11:45 AM with the MDS/Care Plan Coordinator confirmed the quarterly MDS assessment dated [DATE] was not coded for Hospice.

Based on record review, interview and review of the facility policy titled, Pneumococcal Vaccine, the facility failed to ensure Resident #14 was offered the Pneumonia vaccine for 1 of 6 residents reviewed for Pneumonia Vaccines. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Resident #14 has a BIMS (Brief Interview for Mental Status) of 11 out of a possible 15 on 9/24/2018. Review on 11/1/2018 at approximately 10:45 AM of the medical record for Resident #14 revealed no documentation to ensure Resident #14 was offered the Pneumonia Vaccine. Review on 11/1/2018 at approximately 10:45 AM of the form titled, Informed Consent For Pneumococcal Vaccine, revealed no permission to give or refusal of the Pneumococcal Vaccine. An interview on 11/1/2018 at approximately 11:20 AM with the DON (Director of Nursing), confirmed that Resident #14 was not offered the Pneumococcal Vaccine. Review on 11/1/2018 at approximately 11:30 AM of the facility policy titled, Pneumococcal Vaccine, states under, Policy Statement, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Further review on 11/1/2018 at approximately 11:30 AM of the facility policy titled, Pneumococcal Vaccine, states under #4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given or refused) per our facility's physician-approved pneumococcal vaccination protocol.

Based on record review and interview, the facility failed to ensure all members of the interdisciplinary team had input into the care planning process for Resident #6, #13 and #3 for 3 of 12 residents reviewed for Care Plan Participation. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review on 10/31/2018 at approximately 12:44 PM of the Care Plan Conference Summary dated 12/1/2017 revealed the CNA (Certified Nursing Assistant) most involved with the care for Resident #6 and Dietary did not have input into the care planning process for Resident #6. Further review on 10/31/2018 at approximately 12:44 PM of the Care Plan Conference Summary dated 3/2/2018 revealed the CNA most involved with the care for Resident #6 and Dietary did not have input into the care planning process for Resident #6 and review of the Care Plan Conference Summary dated 9/21/2018 revealed dietary did not have imput into the care planning process for Resident #6. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review on 10/31/2018 at approximately 3:48 PM of the Care Plan Conference Summary dated 2/23/2018 revealed that Dietary did not have input into the care planning process for Resident #3. Further review on 10/ 8 at approximately 3:48 PM of the Care Plan Conference Sheet dated 9/27/2018 revealed Dietary did not have input into the care planning process for Resident #3. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review on 11/1/2018 at approximately 3:15 PM of the Care Plan Conference Summary dated 12/18/2017 revealed the CNA most involved with the care for Resident #13 did not have input into the care planning process for Resident #13. Further review on 11/1/2018 at approximately 3:15 PM of the Care Plan Conference Summary dated 4/17/2018 revealed the CNA most involved with the care for Resident #13 did not have input into the care planning process for Resident #13 and dietary did not have input into the care planning process on 7/17/2018. During an interview on 11/2/2018 at approximately 1:40 PM the DON (Director of Nursing) confirmed the findings.

Based on record review and interview, the facility failed to ensure daily staffing posted included the actual hours worked for each category of licensed and unlicensed nursing staff for the 30 days of staffing reviewed. The findings included: Review on 10/31/2018 at approximately 7:23 PM of the daily posted staffing for licensed and unlicensed personal from 9/29/2018 through 10/29/2018 revealed no actual hours worked by the categories for each shift. An interview on 11/1/2018 at approximately 5:08 PM with RN (Registered Nurse) #1, Nurse Supervisor confirmed that the hours for each category of licensed and unlicensed nursing staff was not posted with the number of staff per shift.

Based on observation and interview, the facility failed to ensure the results of the most recent survey were posted in a place readily accessible to residents and that the notice of the availability of the reports was posted in areas of the facility that are prominent and accessible to the public. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if they knew where the latest State survey inspection report was located. The 4 active participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated the inspection report was located in a holder on the wall in a hallway located down from the activity room. This hallway lead out of the unit into another section of the residential campus and was not frequented by all residents and visitors. Observation of the main lobby of the facility revealed no posting or signage indicating where this report was located. Further observation revealed a small sign listing the location was taped to a post at the nurse's station. During an interview on 11/1/18, the Director of Nursing confirmed this finding.

Based on observation and interview, the facility failed to ensure residents were provided and were aware of contact information for all resident advocacy groups. The facility failed to post contact information that was readily accessible to residents and visitors in the facility. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if they knew where the Ombudsman's contact information is posted. The 4 active participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated this information was posted on the wall in a hallway located down from the activity room. This hallway lead out of the unit into another section of the residential campus. Further observations indicated this information was posted high on the wall and would not be visible and readily accessible to residents in wheel chairs. During an interview on 11/1/18, the Director of Nursing confirmed this finding and informed the surveyor this posting would be lowered on the wall.